Navigation
The Oklahoma Fpws 1 form is an essential document for individuals seeking family planning services through the Oklahoma Health Care Authority. Designed for those 19 years and older, this application requires detailed information about each household member. Applicants must provide names as they appear on Social Security cards, along with demographic details such as race, marital status, and citizenship. The form also inquires about household income, including employment and other sources of income, ensuring a comprehensive assessment of eligibility. To verify identity and citizenship, applicants must submit copies of appropriate identification, such as a driver's license or birth certificate. Furthermore, the form outlines rights and responsibilities, emphasizing the importance of accurate information and the consequences of providing false details. Finally, applicants are instructed to mail the completed form to the Oklahoma Health Care Authority, ensuring that all sections are filled out completely to avoid delays in processing.
Document Properties
| Fact Name | Description |
|---|---|
| Purpose of the Form | This form is used to apply for Family Planning Services under the SoonerPlan program for individuals aged 19 and older. |
| Mailing Address | Completed applications must be mailed to the Oklahoma Health Care Authority, Attention: FPW SoonerPlan, PO Box 18276, Oklahoma City, OK 73154. |
| Required Documentation | Applicants must provide a copy of each household member's driver's license or government-issued ID, as well as birth certificates when available. |
| Employment Verification | The form requires information about household employment status, including gross earnings and frequency of pay. |
| Governing Law | This application is governed by the Oklahoma Statutes Title 63, Section 5011 et seq., which relates to public health and family planning services. |
Common mistakes
-
Incomplete Information: One common mistake is failing to complete every item on the form. Each section must be filled out, as incomplete applications can lead to delays or denials of services.
-
Incorrect Names: Individuals often do not list names exactly as they appear on Social Security cards. This can cause confusion and may result in processing issues.
-
Missing Documentation: Applicants frequently forget to include required copies of identification, such as a driver’s license or birth certificate. Omitting these documents can hinder the verification process.
-
Errors in Employment Information: Providing incorrect details about employment, such as gross earnings or payment frequency, is another common error. Accurate reporting is essential for determining eligibility.
-
Not Reporting Changes: Some applicants fail to inform the Oklahoma Health Care Authority of changes in income or household composition within the required timeframe. This can affect ongoing eligibility for services.
Popular PDF Documents
Oklahoma Tax Commission Agriculture Exemption Permit - Affidavits expire two years from the filing date, after which renewal is necessary.
For those looking to ensure their affairs are in order, understanding the importance of a durable Power of Attorney form is key in navigating complex financial and medical decisions. To explore more about this vital legal document, you can visit the site for a comprehensive overview of the Power of Attorney process here.
How Do I Transfer a Car Title - This form offers detailed instructions for completing and submitting requests.
Oklahoma Accident Report Online - The severity of injuries sustained by individuals involved is categorized.
Misconceptions
- Misconception 1: The FPWS 1 form is only for women.
- Misconception 2: You do not need to provide identification.
- Misconception 3: The application can be submitted without any supporting documents.
- Misconception 4: Only low-income individuals can apply for services.
- Misconception 5: You can submit the application online.
- Misconception 6: The application process is quick and does not require follow-up.
This form is designed for individuals aged 19 and older, regardless of gender. Both men and women can apply for family planning services.
All U.S. citizens applying for family planning services must verify their identity. This includes submitting a copy of a driver's license, government-issued ID, or other accepted forms of identification.
To complete the application, it is necessary to include relevant supporting documents. This may include proof of citizenship, income verification, and identification.
The FPWS 1 form is available to all eligible individuals, not just those with low income. Eligibility is determined based on various factors, including residency and citizenship.
Currently, the FPWS 1 form must be mailed to the Oklahoma Health Care Authority. There is no online submission option available.
The application process may take time, and applicants should be prepared for potential follow-up requests for additional information or clarification.
Preview - Oklahoma Fpws 1 Form
STATE OF OKLAHOMA
Oklahoma Health Care Authority
Application for Family Planning Services
This Family Planning Services/SoonerPlan application is used for individuals 19 years of age and older. Please complete every item on this form. If more space is needed, use a separate sheet of paper. Mail the completed application form to Oklahoma Health Care Authority, Attention: FPW SoonerPlan, PO Box 18276, Oklahoma City, OK 73154. If you need assistance completing this form, contact your local Oklahoma Department of Human Services (OKDHS) county ofice.
1.Tell us about everyone living in the household. Show the names as they appear on their Social Security card.
Race - Please use one or more of the following codes to describe your race(s) and or ethnic group: A = Asian; B = Black;
H = Hawaiian/Paciic Islander; I = American Indian/Alaskan Native; S = Hispanic; W = White Sex: M = Male; F = Female
NAME |
Relation- |
Social |
Date of |
Marital |
SEX |
Race |
Hispanic |
Okla. |
U.S. |
Tribal name or alien |
|
(irst, middle, last) |
ship to |
Security |
Birth |
Status |
|
|
|
or Latino |
resident |
citizen |
registration number |
|
person 1 |
number |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Person 1 |
|
|
|
|
M |
|
YES |
YES |
YES |
|
|
|
|
|
|
|
F |
|
|
NO |
NO |
NO |
|
|
|
|
|
|
M |
|
YES |
YES |
YES |
|
|
|
|
|
|
|
F |
|
|
NO |
NO |
NO |
|
|
|
|
|
|
M |
|
YES |
YES |
YES |
|
|
|
|
|
|
|
F |
|
|
NO |
NO |
NO |
|
|
|
|
|
|
M |
|
YES |
YES |
YES |
|
|
|
|
|
|
|
F |
|
|
NO |
NO |
NO |
|
|
|
|
|
|
M |
|
YES |
YES |
YES |
|
|
|
|
|
|
|
F |
|
|
NO |
NO |
NO |
|
2. How do we contact the above household? (Please print)
|
|
Street or P.O. Box |
mailing address |
|
|
|
City |
|
|
|
|
State |
Zip |
||||
|
|
Finding address, if different Street address |
|
|
|
City |
|
|
|
|
|
Zip |
|||||
|
|
|
|
|
|
|
|
|
State |
||||||||
|
|
|
|
|
|
|
Day time |
|
|
|
|
|
|
|
|
||
|
Area code |
|
Home phone number |
Area code |
phone number |
|
Area code |
Number for messages |
|
|
|
||||||
|
Ofice Use Only |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
Case name |
|
|
|
|
Case no. |
County |
|
Supervisor |
|
|
District |
||||
OKHCA Revised |
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
||||||||
Application for Family Planning Services |
3.For all U.S. citizens needing family planning services, identity must be veriied. Please mail a COPY of each person’s drivers license or government issued ID card with picture, school ID with picture, tribal CDIB card, or U.S. military ID card.
4.For all U.S. citizens needing family planning services, citizenship must also be veriied. Complete the information below. If available, mail a COPY of each person’s birth certiicate with this application.
Name (irst, middle, last) of the |
Name as shown on their birth |
County of |
State of |
Mother’s maiden name (irst, |
household member needing family |
certiicate (irst, middle, last) |
birth |
birth |
middle, last) as shown on the applicant's |
planning services |
|
|
|
birth certiicate |
|
|
|
|
|
Person 1 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
5. Is anyone in the household employed? Yes □ No □
Employer’s name, address and phone number
or self employment information
Who earns this money?
Gross earnings per pay period?
How often paid? (weekly, every other week, twice a month, monthly?)
OKHCA Revised |
Pg 2 |
Application for Family Planning Services |
6. Does anyone in the household get any other money or income? Yes No Some examples of other income are:
Social Security/SSI |
Other Pensions |
Support (alimony or child support) |
Annuities/Trust |
Worker’s Compensation |
Veteran’s Beneits |
Interest, such as C.D., stocks, bonds |
Railroad Retirement |
Military Allotment |
Royalties/Gas/Oil |
Money from friends, relatives, etc. |
Unemployment |
Rental |
Other, specify ____________________________________ |
|
|
If yes, give us the following information.
Name of person
money is for?
Source of money?
How much
money?
How often received?
7. Does anyone needing family planning services have health insurance? Yes No If yes, answer the following:
Insurance company name, address and phone number
Group or
policy
number
Person
covered
Type of coverage (major medical, dental, HMO, etc.)
Effective
date
Policy holder’s name and Social Security number
Relationship of
policy holder
to insured
OKHCA Revised |
Pg 3 |
Application for Family Planning Services |
Rights and Responsibilities
The information I give on this form is true and correct to the best of my knowledge. I realize if I give information that isn’t true OR if I withhold information, I can be lawfully punished for fraud or perjury. I may also have to
I understand that the information I give on this application both verbally and in writing will be checked. I agree to help do that and to let SoonerCare get needed information from government agencies, employers, medical providers and other sources.
I know that our Social Security numbers will be given to other government agencies to get information needed to prove eligibility.
I know I am required to help the Oklahoma Department of Human Services (OKDHS) or the Oklahoma Health Care Authority (OHCA) to identify and locate those absent parents who might be liable for the costs of medical care to me or others in my family receiving SoonerCare.
I give permission for SoonerCare to: (1) collect payments from anyone who is supposed to pay for medical care, (2) share necessary medical information with any insurance company, person or entity who is responsible for paying the bill, and (3) inspect any of my medical records to determine the compensability of claims for services. I also give permission to any of my medical providers or home care providers to give information to the OKDHS or the OHCA to make payment or overpayment decisions.
I agree to tell SoonerCare within 10 days if there are any changes in our income, the people who live in our home, where we live or get our mail, and/or our health insurance.
I know that I can ask for a fair hearing if I think the decision made on my case is unfair, incorrect or made too late.
I also know that my application for SoonerCare cannot be denied because of race, color, sex, age, disability, religion, nationality or political belief.
13.ASSIGNMENT: I do hereby transfer, assign and authorize payment to the Oklaho- ma Health Care Authority (OHCA) all claims I have or may have against health insur- ance or liability insurance companies, or other third parties. This covers all payments for medical services made by OHCA.
Yes No
This Application will be denied if you check NO to this question.
14. Your Signature______________________________ Date _____________
For ofice use only 
Date received __________________________
ELIGIBLE Yes No
Signature _____________________________
Date _________________________________
OKHCA Revised |
Pg 4 |
FAQ
What is the purpose of the Oklahoma FPWS 1 form?
The Oklahoma FPWS 1 form is used to apply for family planning services through the SoonerPlan program. This application is specifically for individuals who are 19 years of age and older. It collects necessary information to determine eligibility for family planning services provided by the Oklahoma Health Care Authority.
How should I complete the FPWS 1 form?
It is important to fill out every item on the form accurately. If you need additional space for any section, you may use a separate sheet of paper. Make sure to include all household members and provide their names as they appear on their Social Security cards. If you encounter any difficulties while completing the form, reach out to your local Oklahoma Department of Human Services (OKDHS) county office for assistance.
Where do I send the completed FPWS 1 form?
Once you have completed the application, mail it to the Oklahoma Health Care Authority at the following address: Attention: FPW SoonerPlan, PO Box 18276, Oklahoma City, OK 73154. Ensure that the form is sent to this address to avoid any delays in processing your application.
What identification do I need to provide?
For all U.S. citizens applying for family planning services, you must verify your identity. This involves mailing a copy of a government-issued ID that includes a picture, such as a driver’s license, military ID, or school ID. Additionally, you should provide copies of birth certificates for each household member needing services, if available.
What if someone in my household has health insurance?
If any household member has health insurance, you need to provide specific details on the application. This includes the name of the insurance company, the policy number, and the type of coverage. It is crucial to include this information as it helps determine the extent of coverage available for family planning services.
What are my rights and responsibilities when applying?
By submitting the application, you acknowledge that the information provided is true and accurate to the best of your knowledge. You have the responsibility to report any changes in income, household composition, or health insurance within 10 days. Additionally, you have the right to request a fair hearing if you believe that a decision regarding your case is unfair or incorrect.
Documents used along the form
The Oklahoma FPWS 1 form is an essential document for individuals seeking family planning services. However, several other forms and documents often accompany it to ensure a complete application process. Here’s a list of these related documents, along with brief descriptions of each.
- Proof of Identity: This document verifies the identity of each household member. Acceptable forms include a driver's license, government-issued ID, or a school ID with a photo.
- Proof of Citizenship: A birth certificate or other documents that confirm U.S. citizenship are required for all applicants seeking family planning services.
- Income Verification: This includes pay stubs, tax returns, or other documentation that shows the household’s income. It helps determine eligibility for services.
- Health Insurance Information: If anyone in the household has health insurance, details such as the insurance company name, policy number, and type of coverage must be provided.
- Texas Real Estate Purchase Agreement: This document is essential for any real estate transaction in Texas, detailing the terms and conditions of the sale. More information can be found at UsaLawDocs.com.
- Household Information Form: This form gathers details about everyone living in the household, including their relationship to the applicant and demographic information.
- Consent for Release of Information: This document allows the Oklahoma Health Care Authority to obtain necessary information from other agencies or employers to process the application.
- Fair Hearing Request Form: If an applicant believes their case has been unfairly handled, this form can be submitted to request a review of the decision.
- Assignment of Benefits Form: This form allows the applicant to assign their health insurance benefits to the Oklahoma Health Care Authority for payment of medical services.
Having these documents ready can streamline the application process for family planning services. It’s important to ensure that all required information is accurate and complete to avoid delays. If you have questions about any of these forms, don't hesitate to seek assistance from local authorities or support services.
Guide to Using Oklahoma Fpws 1
Completing the Oklahoma FPWS 1 form is essential for individuals seeking family planning services. This application requires detailed information about your household, income, and health insurance. Once filled out, it should be mailed to the Oklahoma Health Care Authority for processing. Follow the steps below to ensure you provide all necessary information accurately.
- Begin by listing everyone living in your household. Write their names exactly as they appear on their Social Security cards.
- Indicate each person's relationship to you, their date of birth, marital status, sex, race, and whether they are a U.S. citizen or Latino.
- Provide your contact information, including your mailing address and any other relevant addresses if they differ.
- Attach a copy of a government-issued ID for each person needing family planning services. This could include a driver's license, school ID, or military ID.
- Complete the citizenship verification section. Include the name of the household member needing services, their birth certificate details, and their mother’s maiden name.
- Answer whether anyone in the household is employed. If yes, provide details about their job, including employer information and gross earnings.
- Indicate if anyone receives other forms of income. If yes, specify the source and amount of income received.
- State whether anyone needing services has health insurance. If yes, provide the insurance company details, policy number, type of coverage, and the policyholder’s information.
- Review the Rights and Responsibilities section to ensure you understand the implications of the information provided.
- Sign and date the application at the bottom to certify that the information is accurate.
After completing these steps, mail your application to the Oklahoma Health Care Authority at the address provided. If you have questions or need assistance while filling out the form, consider reaching out to your local Oklahoma Department of Human Services office for help.